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A "List of Covered Drugs" is also known as a Formulary or a Drug List. The prescription drugs on this list are selected by the plan in consultation with a team of physicians and pharmacists who represent the prescription therapies believed to be part of a quality treatment program. The Formulary or Drug List is updated regularly with updates posted monthly. New medicines are added as needed, and medicines that are deemed unsafe by the Food and Drug Administration (FDA) or a drug's manufacturer are immediately removed. The Formulary includes both brand-name and generic drugs, and must meet the requirements set by Medicare. Medicare has approved the plan's drug list. For more information about your drug coverage, please review your Evidence of Coverage.
The Formulary or drug list includes both brand-name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally it works just as well as the brand-name drug, but costs less. There are generic drug substitutes available for many brand-name drugs.
To find out or search if your prescription drug is covered, you have the following options.
You may locate drugs by name in the Online Formulary Search Tool. You can search for your prescribed medications by the name of the drug, therapeutic category, or drug class.
A complete list of covered prescription drugs is available. Memorial Hermann Advantage HMO members may now request to receive a printed Formulary in the mail. Please click here to complete the request form:
You may also select from the options below.
The plan does not cover all prescription drugs. In some cases, Medicare does not allow any Medicare plan to cover certain types of drugs (for more information about this, refer to your Evidence of Coverage, in Chapter 5). In other cases, we have decided not to include a particular drug on the drug list if another comparable drug is available on our Formulary.
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these requirements to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which makes your drug coverage more affordable.
In general, our rules encourage you to get a drug that is safe and works for your medical condition. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
Memorial Hermann Advantage requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescription(s). If you don't get approval, Memorial Hermann Advantage may not cover the drug.
In some cases, Memorial Hermann Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
In most cases, your prescription drugs are filled at Memorial Hermann Advantage's network of pharmacies. A network pharmacy is a pharmacy that has a contract with the plan to provide your covered Medicare Part D prescription drugs. To verify if a pharmacy is part of our network, please contact Customer Service at (844) 860-6750 (TTY 711). You can also download a copy of our Pharmacy Directory or visit our website's online pharmacy search tool.
There are two options available to you through Costco Mail Order Pharmacy: traditional mail order or online enrollment. For more information on the Costco Mail Order Pharmacy and for ordering instructions, please click here.
To obtain prescription drugs by mail, use the following mail-order form or call Costco Mail Order Pharmacy Member Services at (800) 607-6861 (TTY 711), 7 a.m. to 9 p.m. CT, Monday - Friday, 11:30 a.m. to 4 p.m. CT, Saturday – Sunday. Prescription drugs that you get through any other mail order service are not covered.
You can use the mail order service to fill prescriptions for many drugs that are on the formulary list. When you order prescription drugs by mail, you may order up to a 90-day supply of the drug.
For more information on home delivery (mail order) information, please also visit the Costco Mail Order Information section on our Pharmacy FAQ page.
For instructions on how to enroll for prescriptions online with Costco Mail Order, click here.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To ensure that Memorial Hermann Advantage will allow an out-of-network pharmacy before you fill your prescription, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription.
If you go to an out-of-network pharmacy due to a health emergency, you may have to pay the full cost (rather than paying just your co-pay) when you fill your prescription. In the event of using an out-of-network pharmacy for an emergency, you can ask us to reimburse you for our share of the cost by submitting a paper claim form called a Direct Member Reimbursement (DMR).
However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy’s price may be higher than a network pharmacy’s. Regardless of the amount, we can only reimburse you the amount that we would have paid if you had the prescription filled at a network pharmacy. Even though you may not receive the full amount you paid in reimbursement, the amount that you paid may still be counted toward your required out-of-pocket costs in reaching the catastrophic stage.
Generally, if you are taking a drug on our Formulary that was covered at the beginning of the year, we will not discontinue the drug or add new restrictions during the covered year except when a new, less-expensive generic drug becomes available, or if new information about the safety or effectiveness of a drug is released. Most of the changes in drug coverage happen at the beginning of each year (January 1). The Formulary may change during the year for the following reasons:
These changes to our Formulary are updated monthly; and updates are provided with a monthly Formulary Addendum. If your drug has these additional restrictions or limits, you can ask Memorial Hermann Advantage to make an exception to our coverage rules.
If a change impacts your current drug regimen, we will notify you of the Formulary change at least 30 days before the date that the change becomes effective. Your doctor will also be informed about this change, and we can work with you to find another drug for your condition. However, if the Food and Drug Administration (FDA) deems a drug on our Formulary to be unsafe, if the drug's manufacturer removes the drug from the market, or if a new generic drug replaces a brand name drug on the Drug List, we will immediately remove the drug from the Formulary and provide notice to members who take the drug. In nearly all cases, we must get Medicare approval for changes made to the Formulary.